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Time after Time: Recurrent Preterm Birth

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Trying to figure out when your little one will make his/her first appearance is a game many of us have played. And while family and even office pools are often centered on birth stats (I’ll take a girl on Tuesday, May 18, weighing 7 lbs., 2 oz.), when the grand finale will actually take place is really nothing more than a guessing game, minus those who have scheduled a C-Section or an induction! No matter how much you like fours or sevens, evens or odds, babies come when babies come. Bottom line, don’t take this bet to Vegas. The odds are not likely to be in your favor, and you probably need to save your money. Diapers aren’t cheap! Just like those who go to Vegas and count cards, we OBs have some ways to “cheat” and figure out who is likely to deliver early, sometimes even weeks before their due date. And although we wish it was because we were all-knowing, it’s really because women who have a history of a spontaneous preterm birth (delivery at less than 37 weeks because of preterm labor or preterm rupture of membranes) are significantly more likely, about 1.5–2X, to be exact, to deliver early in their next pregnancy. In fact, one of the strongest risk factors for preterm birth is a prior preterm birth. Add to that the number of times you delivered early (one vs. two vs. three, etc.) and how many weeks you were at delivery (24 vs. 26 vs. 28, etc.), and you have an even better idea about whose baby will make their debut before the curtain officially rises.

The more times you delivered early and the earlier you were (24 vs. 28 weeks), the more likely you are to be early again. There are other risk factors for preterm delivery, like a history of cervical surgery, UTIs and genital tract infections during pregnancy, smoking, substance abuse, low maternal pre-pregnancy weight, and short inter-pregnancy interval. But none is nearly as strong as a previous history of a preterm birth. Simply stated, a history of preterm birth is the odds-on favorite for a preterm birth in your next pregnancy. So why do we care about when and if a preterm delivery occurs? Sure, we love to win a good family/office pool as much as the next gal, but you can be sure that whether we take home the pot is not what’s perturbing us. What keeps us on our toes is the following: babies who are born premature (a.k.a. early) have a much higher risk of serious morbidity and even mortality, particularly in the first year of life.

Nothing good comes out of an early delivery, except maybe a few less pounds gained and stretch marks formed. Pregnancy was meant to go the distance, that is, 39 weeks, and when it is cut short, bad things can happen to your baby. To prevent a recurrent preterm birth, your OB will be on your speed dial—and you on theirs! We want to know how and what you are feeling. We also like to see your cervix via vaginal ultrasounds every couple of weeks. These checkpoints can clue us into what might be coming (a.k.a. another preterm birth). If things start to change, say, the length of the cervix gets shorter or the cervical opening begins to dilate, we will call “Freeze” and often admit you to the hospital for medication and monitoring. Additionally, women who went early before will usually be prescribed weekly IM shots, which are progesterone injections starting between 16–24 weeks. And while the shots may be a big pain in the butt  —we’re not going to lie; that needle is long!—they are a big player in the prevention of recurrent preterm birth.

Although we can never be sure whose baby is likely to break out of the womb before his/her time is up, we can narrow down the lineup to a few of the most likely candidates. And because we don’t like to make any wrongful convictions, we use the evidence (a.k.a. what happened in your previous pregnancy) to hone in on those who have planned a successful escape in the past. While we may put you on high surveillance (frequent office visits, ultrasounds, weekly injections, and possibly even reduced activity) to encourage this pregnancy to go the distance, it’s a small price to pay for your baby’s safety. While we may not be spot on with the weight and date of your little one, we will be on the money with how best to prevent a recurrent preterm birth. Here, we are not willing to gamble!

A Weighty Issue: the More Pounds, the More Problems

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“Eating for two” has long been the slogan that has summed up a woman’s eating habits during pregnancy. Whatever the baby wanted, the lady got! From pancakes to pizza and grilled cheese to goat cheese, it was bottoms up (no matter how big your bottom, your top, or your baby got)! The sky or the sundae was the limit, and weight was not a worry. But pregnancy is no longer bon bons and “baby on board” tee shirts. Food choices are important, and OB/GYNs are making weight gain a weighty issue during pregnancy.

During pregnancy, both you and your baby sort of are what you eat. Long gone are the days of limitless donuts and Doritos. And although cravings don’t need to be curbed, more recent medical data show that they should be curtailed. Additionally, monitoring what you put out as well as what you put in is recommended. Caloric intake and energy output can make a sizable difference in your baby’s size and even his or her future health. In 2009, the Institute of Medicine (IOM) released a new set of guidelines for weight gain during pregnancy. These recommendations are based on your pre-pregnancy body mass index (BMI). So get out your calculator and, ugh, that dreaded scale.

To calculate BMI, you take your weight (in kilograms) and divide it by your height squared (in centimeters); so if you are 5’5 and weigh 135, your BMI would be 22.46. Your next question is: what does that mean? Is 22 a good number?

A “good” number as defined by the IOM is a BMI between 18.5 and 24.9; this is considered a normal weight. The highs and lows go like this…a BMI less than 18.5  is underweight. A BMI between 25 and 29.9 is overweight, and a BMI greater than 30 is obese.

With these numbers in mind, the recommendations are as follows:

  • Women who are underweight should gain between 28 and 40 pounds during pregnancy.
  • Women who are normal weight should gain between 25 and 30 pounds during pregnancy.
  • Women who are overweight should gain between 15 and 25 pounds during pregnancy.
  • Women who are obese should gain between 11 and 20 pounds during pregnancy.

While one size never fits all, there are exceptions to the rule, particularly women who are carrying multiples. If you are doing double duty, you don’t need to double your weight gain, but you do need to put on a few extra pounds. Recommendations are not rules, and even some rules are meant to bend and be broken. Don’t beat yourself up every time you step onto that scale: you are not trying to make weight for a wrestling match. These numbers are a guideline, not a guillotine.

Why do we care so much? Can’t there just be nine months when you are not a slave to your scale? We care because excessive weight gain during pregnancy has been linked to a whole buffet of problems: diabetes during pregnancy, fetal macrosomia, high blood pressure, birth defects, premature delivery, stillbirth, cesarean section, complicated vaginal deliveries, and childhood obesity. The menu of problems is large and continues to grow with more research.

We as OB/GYNs are pressing the issue and pressuring you to watch your weight because really bad things can happen to both you and your baby when you don’t. Last, the more weight you gain during your pregnancy, the harder it is to lose after pregnancy is done. While most of us can’t be Heidi Klum at a Victoria’s Secret fashion show one month after delivery (I mean, really, how did she do that?), how much you gain during pregnancy is equal to how much you will need to lose post-pregnancy. So fill your plate the first time, but resist the urge to go back for seconds. It’s not worth it.

Going, Going, Gone: Hair Loss in the Postpartum Period

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Staring at the mirror in the postpartum period can be rough: black circles under your eyes, stretch marks on your thighs, and a belly that looks like it is still carrying a baby. And if that’s not enough to make you feel really awesome, a couple of months after delivery you begin to notice that the drain of your shower is clogged with hair. Bald spots on your forehead abound, and you begin to wonder what in the world is going on. How can those luscious locks go from plentiful to pitiful in just a couple of short months? Are you losing your hair along with your mind from lack of sleep? No, not really. While you might be losing your mind from lack of sleep, you are losing your hair from a massive change in the hair cycle.

Yes, hair has a cycle. It grows in phases and in stages; anagen, catagen, and telogen. And unlike other stages or cycles, when it comes to hair all three occur on one noggin simultaneously. So while the majority of hair (about 85%) on one’s head is in the anagen phase, one hair strand can be resting in telogen while another can be growing in anagen. You still with us? In addition to the various stages, the hair cycle is actually fairly lengthy, with a growth of about  .5 inches/month. This might give you pause before chopping it all off! While the length of time a hair spends in anagen is largely determined by genetics, in general, the longer hair is in anagen, the longer it will grow.

During pregnancy, there is a substantial increase in the growth or anagen phase relative to the resting or telogen phase; this translates into that Pantene commercial-like hair that you see while carrying your plus one. It flows, it glows, and it really never looked so good. A common misconception is that this unprecedented growth is the result of prenatal vitamins. And while prenatal vitamins are good for you and for your baby, they are not the reason behind that magnificent mane. High levels of estrogen prolong the anagen or growth phase. So rather than having 85% of your hair in growth and the rest in transition or rest, you may have 90-plus percent in growth while you are growing your little one. This translates into some luscious locks while pregnant! Side note…extra hair growth does not only occur on your head. It will also be seen in some of your not-so-favorite places (a.k.a. bikini line, armpits, legs, and lips). Bottom line, you may become quite friendly with your local beauty salon.

Postpartum, the ratio is reversed, and about one to five months after delivery, telogen takes the lead. With “T” in the lead, months of hair loss follow (UGH!). And in contrast to the normal loss that occurs daily when not pregnant (take a look at your brush…we all lose about 50–100 strands on a normal day), post-partum hair loss can last for up to 15 months.

Breastfeeding will worsen the situation and promote continued hair loss (what else will this kid take from me?). Continuing to take vitamins, maintaining healthy habits, drinking lots of water, and getting as much sleep as possible (yes, we get that the last one is impossible!) can help get things back on track. Additionally, modifying your hair regimens and treatments may also have a positive impact on your ponytail. So while you may have been dreaming about going back to your Keratin treatment, it is best to talk to your GYN and your hair stylist; they will likely have some good tips on how to treat your tresses.

The postpartum period is often dominated by creativity. And while we don’t mean drawing and designing, we do mean thinking of ways to do things with one hand, one minute of freedom, and what may feel like one functioning brain cell. Coming up with novel hairstyles and clothing options also require creativity. Given the hair loss, you may need to employ bandanas and sweatbands to cover your hairline. But despite these short-lived innovative styles, your hair will come back. It may not be exactly the same (unfortunately, almost nothing really is, post-baby), but you will be able to brush without going bald—we promise!

Pain in the Butt: Hemorrhoids

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Talking about your tush, particularly what’s coming out of it and how you feel when these things come out, is no one’s idea of a good dinner conversation. Even during a ladies’ lunch, it’s rare to hear someone say, “So, do you have pain with defecation?” And no matter what you like to call it (defecation is the medical way to say bowel movement), most of us don’t like to call attention to our bowel habits. However, after pregnancy and delivery, pooping can become a pretty big problem. Here’s why…

Pregnancy is a pressure-filled time (and we are not referring to the pressure of knowing that a baby is about to come and change your whole life). During pregnancy, your blood volume increases, you hold on to more fluid, and you usually gain a fair amount of weight. All of these pluses lead to an increase in the pressure bearing down on things like your ankles, your joints, your pelvis, and even your rectum. The local pressure on the anus can lead to varicosities (dilated/swollen blood vessels) in the anal canal (a.k.a. hemorrhoids). Additionally, constipation, a common complaint of pregnant and postpartum women, will make matters worse and will increase the pressure on an already pressured system.

Although hemorrhoids come in two “varieties” (internal and external), most of us are only aware of the external ones. The reason is that the internal ones are sort of invisible. They rarely cause pain or discomfort and only present themselves with rectal bleeding. Therefore, unless you go looking for a cause for the bleeding, you probably won’t find them.

External hemorrhoids, however, are much “flashier.” They cause a pretty good amount of pain with defecation and often move, or prolapse, to the outside of the anus after a bowel movement. On occasion, blood clots form within these prolapsed external hemorrhoids, making them doubly painful. The extra blood will not only cause extra pain but it can also turn the hemorrhoid a bluish purple color, which can cause a good amount of fear. However, the reality is that even though they look and feel bad, they are not dangerous or serious. No matter how little we may talk about hemorrhoids, they are super common, particularly in the last trimester of pregnancy (when pressure is at its peak) as well as during the post-partum period. As you can imagine, labor and all that pushing will not help the hemorrhoid situation, and most women report even more hemorrhodial discomfort (pain, bleeding, rectal itching) in the postpartum period. Not fun.

And while hemorrhoids can be a major pain in the butt, there are many treatment options available, even for pregnant women. From the most basic (anti-inflammatory, anti-itching, and pain relief creams) to the most aggressive (surgery), we have ways to take care of those hemorrhoids and those nagging symptoms. Additionally, changing your diet and increasing fluid and fiber intake can decrease constipation. Decreased constipation = less pushing = less pressure on the rectum = less hemorrhoids.

How your bottom feels can be the basis of how bad (or good) your day is. Let’s face it, we all need to sit, and we all need to have bowel movements—without pain. If you dread defecating, you need to dial up your OB/GYN. Although talking to anyone about your tush seems totally off limits, it’s a pretty standard part of an OB/GYN’s day. We hear this stuff all the time. And if we can’t help you return to the toilet without terror, we have many GI (gastroenterology) friends who can. We promise your hemorrhoids are not here to stay.

When Everyone’s Positive Pregnancy Test Is Like A Punch In The Stomach

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Pregnant women are everywhere. They are on the street, on the subway, in the shopping mall, and in just about every store you step into. And when you are having trouble getting pregnant, their presence seems pervasive. Like ants on a hot summer day…no matter what you do, they just keep marching towards you!

Dealing with the “we are expecting” texts, the “coming in December 2016” Facebook posts, and the “join us as we shower our little one with love” emails is not easy when you continue to come up short each month. You start to wish that you lived in a bubble where no babies or women about to birth them were allowed. But unfortunately, no matter how much you wish them away, they will still be there when you open your eyes. Here are a few words of advice on dealing with the emotional aspects of infertility.

First things first, it is important to recognize that what you are going through stinks, big time. There is just no easy or fancy way to say it or scream it: it just stinks. In fact, infertility is one of the most distressing events that a couple or individual will ever face. It is such a devastating diagnosis that many in the mental health arena liken infertility’s impact to cancer’s.

Infertility can evoke feelings of loss, isolation, and a major lack of control. It can lead to anxiety, depression, and downright emotional mayhem. Relationships become strained, work performance can be compromised, and social interactions can become limited. If some or all of the above have happened to you, you are not alone.

And while we certainly know a lot about infertility and how to treat it, we are most certainly not the experts on how to treat the mental health issues caused by infertility. However, what we do know are friends in high places (a.k.a. mental health providers), and we can help point you in the right direction. We are big fans of our social workers, psychologists, and psychiatrists who specialize in the treatment of the psychological impact of infertility. They are major players on our infertility treatment team, and we frequently work together to provide couples with their help.

We are also serious supporters of support groups (both in person and online) as well as advocacy groups devoted to supporting women and couples who are struggling with infertility. Such groups can help you navigate the process, cope with physical and emotional changes due to fertility diagnosis and treatment, and deal with the fear surrounding the treatment and possible outcomes (unfortunately, things may not work the first time). Bottom line, they can do a lot.

We are going to say it again: infertility stinks. It’s okay to feel sad, it’s okay to feel frustrated, and it’s okay to want to scream (and maybe even throw something at the wall). However, getting down on yourself or your partner won’t change your situation. Withdrawing from friends, family, and your daily activities may limit the number of pregnant women you see, but it won’t change the way you are feeling. But asking for help, seeking out support groups, enrolling in counseling, and perhaps initiating medications will make a difference. And while you can’t totally avoid pregnant women or the “I am pregnant on the first try” text message, you can avoid the store Buy, Buy Baby on a Saturday afternoon. Trust us, it’s no fun there anyway!

Are We Doing Leftovers Tonight…What’s in the Freezer?

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Nothing tastes better the day after, the week after, or certainly after it’s been sitting in the freezer for a while (except maybe Haagen Dazs coffee ice cream!). With this being said (and true), it’s hard to believe that frozen embryos are as good as, if not better, than fresh embryos. Explaining this to patients can be incredibly confusing—and rightfully so. Who wouldn’t think that fresh chicken is better than the stuff you defrosted last night?

Given our perception of food and what happens after a stint in the fridge or freezer, it can take a while to convince patients to take a pass on the fresh embryo transfer and opt for a frozen one. However, embryo freezing has come “a long way, baby” since the first baby was born in Australia in 1984. Currently, nearly half of IVF transfers in this country are frozen embryo transfers. So why the shift? Changes in the freezing process and techniques have resulted in frozen embryo transfer success rates that in some cases top those of fresh cycles. Data from our OB friends have shown that babies born after frozen cycles do better in utero and as infants than babies born after fresh cycles! Large studies have shown lower rates of preterm delivery, low birth weight, growth restriction, and mortality after frozen embryo transfers—pretty impressive stuff.

Furthermore, the congenital anomalies/malformations that arise after frozen embryo transfers are no different than after fresh transfers. Your next question is likely…why? What could possibly be better about something that was frozen and then thawed rather than something that was hot (or fresh) off the press? Here’s the deal.

Researchers believe that it has something to do with the uterus and the endometrium’s ability to receive the embryo after a fresh vs. a frozen embryo transfer. The thought is that maybe the high estrogen levels seen in many fresh IVF cycles, while beneficial to the ovaries, may be detrimental to the uterus. An “unhappy uterus” means “unlikely to have implantation.” And if you take it one step further, maybe the high estrogen levels not only decrease the chance of implantation but also the ability of a good placenta to form.

Poor placental development will ultimately translate into poor fetal growth (hence, the higher incidence of growth restriction and low birth weight after fresh embryo transfer cycles). Whatever it is, the data are fairly impressive. And while we are all rah-rah-go frozen embryo transfers for the above reasons, there are also two more important reasons to raise the pom-poms:

  1. When embryos are not transferred back into the uterus during the fresh cycle, it gives your body a chance to go back to baseline. Deep breath in, deep breath out! The pause allows your body and, in many ways, your mind to reset. Without a pregnancy in the uterus to provide the juice to keep the ovaries revved up and enlarged, you will get a period about 7–14 days after the retrieval. And this breather is more than just getting your pants to button again (although it does feel good!). It allows your body to return to baseline and prepare for pregnancy with a more normal hormonal environment.Additionally, for those of us who are exercise fanatics, once you get a period you can resume your normal activities (#run #spin #yoga). While we know that exercise is not the most important thing in the world, it and any activity you do to keep you sane are pretty important. If we can help you maintain some normalcy in the midst of shots, vaginal ultrasounds, and never-ending blood draws, we most certainly want to do that.
  2. Recently, embryo freezing has taken on a whole new meaning; it now is a major player in the genetic testing of embryos game. Call it what you want: PGS, CCS, TE biopsy. Embryo testing has become all the rage. It provides patients with important information, significantly increases success rates, and majorly reduces the twin rate. It’s the triple threat! However, in order to get an accurate read on all of your embryo’s genetic material it takes time. In a fresh embryo transfer cycle, time is of the essence. But if you freeze the embryos, time is also frozen. With the embryos on ice, you have time for chromosomes to be checked and your chances increased.

Bottom line, fertility treatment can be a cold place if you don’t have up-to-date information on what’s going on in the field of reproductive medicine. Be fluid; don’t be “frozen” in your thinking patterns or your plans. Medicine changes faster than ice melts in the summer. Ask your fertility doctor about what’s hot and what’s cold. You might be surprised at what’s hiding behind the frost!

Epidurals, Episiotomies, and Elective C-Sections: What Are the Essentials for a Good Labor?

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From the moment you pee on the stick and see the two lines, the smiley face, or the word pregnant, your mind starts to run wild. Is this for real? Will it be good? Could this really be happening? After dropping about fifty more bucks at the drugstore by taking another three to four tests to confirm what the first showed (trust us, we’ve been there!), the idea of pregnancy and motherhood begins to settle in.

Through deep breaths and calming thoughts, you start to envision what the next nine months will look like. Cravings, nausea, fatigue (sometimes extreme), bloating, spider veins, acne, back pain, and maternity clothes…bring it on! And although you can handle almost any of pregnancy’s curve balls—and there are many—the unknown surrounding how that baby will actually make his or her entrance into this world is probably the most nerve racking. Will there be endless hours of pain where you spend every contraction cursing your labor team (gotta love the movies!), or will it be a peaceful few hours rocking back and forth to the iPod playlist you carefully selected? Whichever it winds up being, you can almost be sure it won’t be what you imagined. It will deviate from your birth plan or your non-birth plan, no matter how hard you will it not to.

Amidst all the unattractive parts of pregnancy, there will be the most attractive things you have ever experienced. You will feel your baby kick. You will listen to your baby’s heartbeat, and you will watch your baby grow. You will think a lot about your future, both immediate and distant, and try to imagine what your days, nights, and years will look like. (Spoiler: the nights will be long, and the sleep, short!) While you can’t know when or how everything will happen during labor, you can take those sleepless nights preparing for a variety of possibilities. By educating yourself (through reputable sources—shout out to Truly, MD!) and talking to your doctor or midwife, you can prepare yourself for what might come. There is a lot to learn and a lot to consider, so we will give you the abridged version.

Epidurals are not your enemy; in fact, they are sort of your fair-weather best friend. (Labor isn’t so long!) Despite all the pros, unfortunately, for some reason there is a lot of negative hype around epidurals, such as:

  • They will cause a C-section.
  • They will hurt your baby.
  • They will cause permanent back pain.

These are simply not true. While epidurals have been demonstrated to increase the second stage of labor (a.k.a. how long it takes you to push that kid out) and increase a woman’s need for labor augmentation (Pitocin), they have not clearly been linked to increased C-sections.

Data show that timing may be the issue, and getting your epidural too early (defined as < 4cm) may be what increases the risk of a C-section. So while we will do our best to coach you through those early contractions sans an epidural, in our opinion, next to the pill, epidurals may be medicine’s best gift to women. Think of any other medical situation where it would be okay for a woman to have intense pain and no pain control. We can’t think of one! So don’t try to be a hero. If the pain is too much, it’s okay to cry mercy. We promise this doesn’t make you a failure. While pain-free labor seems pretty amazing, we would be remiss not to mention that there are some negative side effects with epidurals (headache, temporary weakness/numbness, fever, low blood pressure, rash). However, in general epidurals are incredibly safe and in our opinion a total lifesaver!

Hot topic #2 on the L&D floor. Put your scissors away, because episiotomies (a cut along the perineum to increase space) are no longer standard practice. The routine use of episiotomies is sort of an old-school practice (reference to it can be found in the medical literature for over 300 years!). Historically, it was done to help expedite the pushing process, more space presumably equaling more speed. It was also thought to decrease the incidence of bad tears and future leakage (a.k.a. your dependence on Depends!). But the studies demonstrated that the proof was missing from the pudding. Most evidence showed that the benefits of routine episiotomies were sparse and in more of doctors’ anecdotal experiences (let me tell you about what I’ve seen!) more than evidence-based. Medicine moves faster than a NASCAR racer in the final lap of the Daytona 500; research is the fuel driving the process. Routine episiotomies are out of gas; restricted use is preferred and is the current practice.

Zodiac signs, numbers, days of the week, and months are all important. I mean, if you deliver a Taurus as opposed to an Aries you could be up against a bull versus a ram. But despite your love of certain signs, elective anything when it comes to labor should be carefully considered. Scheduling C-sections and deliveries to fit between scheduled appointments, commitments, and important events has become a popular trend. The “Cesarean delivery on maternal request” (the PC way to say “no medical reason to go under the knife”) encompasses about 2.5% of all births in this country (about 1.3 million births per year). Simply stated, if this is what you want you are clearly not alone. But before you go under the knife, we ask you to consider the potential downsides of this seemingly benign procedure.

While the most common surgical procedure performed on women in the US is a C-section, they are most certainly not risk-free. A C-section is still surgery. You will be in the hospital longer; your baby has a higher chance of respiratory problems. Squeezing through the birth canal squeezes the fluid out of the lungs, while taking the “easy way out” does not allow the fluid to come out, and you are at higher risk of problems in your next pregnancy. Think of it this way: when you fall and cut your knee, you usually get a scab. The area heals, but often a scar remains. As long as it isn’t on your face, you can pretty much deal! Well, when a C-section is performed and the uterus is cut, it (just like your knee) will scab and eventually will heal. But even in the hands of the best OB, it is not uncommon for scar tissue to form on the uterus. Scar tissue on the uterus may be hard to see, but trust us, it is not a pretty sight. While cosmetically, you won’t have a problem (only your OB sees your uterus!), scar tissue can negatively affect your future pregnancies in a pretty big way. Placental implantation problems, uterine rupture, and even the need for a hysterectomy can all occur the next time around.

And in this case, the motto “The more, the better” does not apply. The more kids you have, the more C-sections you will likely need and the worse the situation can become. A planned “C” will decrease your urinary leakage (cough, sneeze, laugh, oops!) in the first year after delivery, but after that, the playing fields between elective C-section and vaginal delivery are pretty much equal. (Basically, we all will be peeing on ourselves at the same rate.) So while it seems simpler, cleaner, and easier, we again remind you that it is surgery, and surgery has risks. Think before you sign up. Read, ask, consider, and investigate.

Flashing alert…we are talking about the elective-not-in-labor C-section, NOT the “I’ve-been-in-labor-for-24-hours-and-pushing-for-four,-and-this-kid-won’t-come-out C-section!” Or this baby is breech and won’t turn C-section.  Trust us, we are not knocking C-sections or those who have them; being awake while somebody is operating on your belly is more than admirable. If you wind up needing a C-section, don’t sweat it. You are no less of a woman, a mom, or a tough chick because you couldn’t push your baby out from below. It’s your voice, your body, and your baby. And as long as you are at least 39 weeks pregnant (one week before your due date or more), you can request an elective-not-in-labor-just-because-I-want-it C-section!

We’ve seen women who swore off epidurals like the devil begging for them and women who signed up for elective C-sections walk onto the labor floor 10cm and pushing. You just never know how it will go. Have an idea what you want—midwife or OB, doula or partner, C-section or vaginal delivery—but be ready to accept the exact opposite. You can print it 100 times, in color and in bold, but it likely won’t change what happens on that fateful morning, afternoon, or evening. In the words of our girl Elsa, “Let it go.” More important than the perfect story or the kickass photo ops is safety (yours and your baby’s).

Hours of painful contractions can blur your ability to reason. That’s what your trusty OB/midwife is there for. Sure, we’ve probably been up with you, but sleepless nights are par for the course for an obstetrician (coffee is our best friend!). Even the best of stories and plans often needs editing. And while chapters 1–10 may not be a New York Times bestseller, it’s the last page that matters most: a healthy mom and a healthy baby. The rest are just words on a page!